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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED 1� I A ^! m JOB ADDRESS l u 0 Q w- B� rT`14^N O A 0 CITY/ZIP I t Ac 1I . L'Q"T J y�yy CROSS STREET 6a ^ ^ APN ZQ r _7-1 O PARCEL SIZE 3'O LAND USE APPLICATION# p I ^�_c1 G�1 l� OWNER NAME A,, t ns �n� -r�/�C Q \ _Z PHONE n \ �- D15"511 /5 l 2� \ w OWNER ADDRESS 1171 0 P w" ') 1 1�A^") Ind CITY/STATEMP TrAL� � 1 S3 Q 1 CONTRACTOR PtAvAnc.E0 cQ0 ��v�fo/1r"�Fn')1A `,. P-HTONE Z-C' ''� - `Ib ) CONTRACTOR ADDRESS S 3 7 .J b A,HAS PO AA A 0 CITY/STATE/ZIP S 1�Cr t� I O/y/ SUBCONTRACTOR/CONSULTANT S A/fit L /T-S "T� 9-1/Q PHONE SUBCONTRACTOR/CONSULTANT ADDRESS It 1/ TTCIYISTATE/ZIP I t I I f I LICENSE +' C-57 C-61 D-09 Fl Other NUMBER 0 O Z f-1 EXPIRATION DATE BILLING PARTY: OWNER ONTRACTOR L SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)L1 Arsenic(4393) INTENDED USE Domestic/Private D Irrigation/Agricultural C Industrial G Water Quality Monitoring Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK J New Well 7 Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Wells) #of wells a Soil Borings) III of borings Geotechnical #of borings D Out-Of-Service Well Out-Of-Service Well Renewal 0 Cross-Connection Repair ❑New Pump U Pump Replacement Pump Repair C Raise Well Casing WELL CONSTRUCTION Drilling Method D Mud Rotary C Air Rotary 7c�-,uger i'Cable Tool C Push Point C Other Proposed Well Depth N/A ft Excavation "J I Yk in diameter 7 Open Bottom Gravel Pack/Gravel Size NIA in diameter I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schad 7 Steel I Plastic Stainless Steel Other Grout Seal Depth 15 ft Meat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water D Bentonite(20%solids) C Other Grout Placement Methodumped C Free Fall 13 Other12 CMCL L Retardant/Accelerator(name) PEDESTAL Installed By n Driller ❑Pump Contractor' IOther U Concrete Pedestal uDimensions:Width It Length ft Thick in L Christy BOX L Stove Pipe PUMP I I Submersible I Turbine i Other HP Pump Set it Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HqyR Af`T],/AN NOTICE REQUIRED FORRIIINSPECTIONS-/P�LEAS(E�CAALL(209)953-7697 C SIGNED / W�-- TITLE m'`'IA�TV DATE Me Aq- VFO 2419 / c T NTA N�, TMENT _ DEPARTMENT USt O LY / Application Accepted By Date V2 6 Area Employee 1 _�iC 4 Grout Inspection By Date - %XPEC�Wlll Permit Pump Inspection By Dale ❑ WAIVER Received Soil Boring Inspection By Date I / F^i/ Constructed Well Depth ft COMMENTS PE SC Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Rawest# C' EHD43-06 6/11/2019 WELL/PUMP PERMIT T